Osseo integration/ orthodontic continuing education

OSSEOINTEGRATION
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com
www.indiandentalacademy.comwww.indiandentalacademy.com

OsseointegrationOsseointegration
 A direct structural and functional connectionA direct structural and functional connection
Between ordered living bone and the surface ofBetween ordered living bone and the surface of
the load carrying implantthe load carrying implant
--Albrektsson et al--Albrektsson et al

BONE
STRUCTURAL
SUPPORT
CALCIUM
METABOLISM

MODELLING
INVOLVES INDIVIDUAL SITES OF BONE FORMATION
OR
RESORPTION THAT CHANGE SHAPE / FORM OF A
BONE
REMODELLING
MECHANISM OF BONE TURN OVER

COUPLED SEQUENCE CELL
ACTIVATION
(A)
BONE RESORPTION
®
BONE
FORMATION
(F)
+
+
BONE
REMODELLING

REMODELLING
PROCESS
CORTICAL
BONE
TRABECULAR
BONE
PARA VASCULAR
CUTTING/FILLING
CONES
ACCOMPLISHED
BY
HEMI CUTTING/
FILLING CONE

TRABECULAR BONE CORTICAL BONE
RATE ;20-30 % /YEAR 2-10% / YEAR
MOST IMPORTANT
CALCIUM RESERVE
IN THE BODY
PREFERENTIALLY
AFFECTS
METABOLIC
FRACTION
CERTAIN SITES ;
INTERFACE OF OSSEO
INTEGRATED
IMPLANTS:
TURN OVER RATE:30%
/ YEAR

ROLE OF BONE TISSUE ON STABILITY
OF IMPLANT
3 DISTINCT TYPES OF BONE
WOVEN
BONE
LAMELLAR
BONE
COMPOSITE
BONE

WOVEN BONE
HIGHLY CELLULAR
RAPID FORMATION RATE : 30 -50 MICRO / DAY
RANDOM FIBRE ORIENTATION
MORE COMPLIANT THAN MATURE OSSEOUS TISSUE
IMPORTANT STABILIZING ROLE IN INITIAL HEALING OF
ENDOSSEOUS IMPLANT.

LAMELLAR
BONE
Principal load bearing tissue
Predominant component of a mature
bone/ implant interface
Rate – 1 mic / day
Highly organized matrix & densely
mineralized

COMPOSITE
BONE
COMBINATION OF PARAVASCULAR
LAMELLAR BONE + WOVEN BONE .
IMPORTANT STEP IN STABLIZATION
OF AN IMPLANT DURING RIGID
INTEGRATION PROCESS.

IMPLANT INTEGRATION
THE CORTICAL BONE RESPONSE
INVOLVES 5 PHYSIOLOGIC STAGES
CALLUS
FORMATION
CALLUS
MATURATION
REGIONAL
ACCELERATORY
PHENOMENON
MATURATION
OF
OSSEOUS
INTEGRATION
LONG TERM
MAINTENANCE
OF
OSSEOINTEGRATION

MOST EDENTULOUS SITES
ARE ATROPIC
RESULT OF
INADEQUATE
MECHANICAL
LOADING
PLACING AN IMPLANT
OVERRIDES
THE ATROPIC
ELICITS
TIME DEPENDENT , LOCALIZED
HEALING RESPONSE
CONTROLLED
BY
CYTOKINES

PERIODONTAL LIGAMENT
VS
OSSEOINTEGRATION
PERIODONTAL
LIGAMENT
width of the PL 0.1 TO 0.2 mm
Providing support to the teeth in visco elastic
manner
Comprises of collagen fires , sharpey's fibres
,
connective tissue ,blood supply.
Has a sensitive proprioceptive mechanism
Capable of detecting and responding to a
wide range of forces.www.indiandentalacademy.comwww.indiandentalacademy.com

Osseo integration
At the light micro scope level
very close adaptation of the bone to the
Implant surface.
With electron micro scope
Gap of 100NM in width
Occupied by intervening collagen rich
zone adjacent to the bone
Amorphous zone adjacent to the implant
Surface
Bone proteoglycans is important in the
Initial attachment of the tissues to the
Implant surface ( ex titanium)

Osseo integration
Can be measured as the proportion of
The implant surface that is in contact
with bone
Greater level of bone contact occur in
cortical than cancellous where marrow
Adjacent to the implant surface .
When implant placed in bone there
should be close fit to ensure stability

ImplantBone
Blood clot
+
Serum /
Bone proteins
Initial response to surgical trauma --- resorption followed by deposition
Critical period of healing process ---around 2 weeks post implant
insertion
Osseo integration as viewed as DYNAMIC PROCESS IN WHICH
BONE TURN OVER OCCURS , BUT NOT AS THE SAME
ADAPTIVE PROCESS WITH IN THE PERIODONTAL LIGAMENT
More akin to an ankylosis , where absence of mobility , no intervening
fibrous tissue capsule is sign of successful osseointegration

No viscoelastic system+ proprioceptive
Forces distributed to the bone and may be concentrated in certain
Areas , particularly around the neck of implant .
( thread types may dissipate the forces effectively )
Excessive forces implant
Result in
Remodeling of the marginal bone
( apical movement of bone margins
With loss of osseointegration )
Type of bone loss
May be slowly progressive to point
When there is catastrophic fracture of
Osseointegration

Osseo integrated
Implants
Act as effective anchorage unit for
Difficult orthodontic movement
Restricts its use to individuals who
have completed their jaw growth

Osteoblast as a controllable determinant of
Bone formation for osseointegration
Important feature of osteoblast
Osteoprogenetor cell
Osteoblast osteocyte
Osteoinduction
osteoblast Synthesize a matrix ( type 1 collagen )
+
Matrix proteins
Regulate matrix mineralization into highly
Specialized tissue
osteogenesis

Osteoblast are autocrine regulatory cells that synthesize & deposit
Growth factors into bone matrix ( these factors released during
Resorption phases of repair & remodeling )
Osteoblast may mediate the systemic & physical signals for the
Recruitment & activity of osteoclast that are integral to the process
Remodeling & repair maintain bone at implant site

Ways to controlled osteoblast activity at
implants
4 aspects of cellular physiology
Osteoblast
recruitment
Osteoblast
Attachment
proliferation
Differentiation
With
Matrix synwww.indiandentalacademy.comwww.indiandentalacademy.com

Osteoblast
recruitment
Depends on signaling to precursor cells
By
cytokines
BMP directly involved in osteoblast recruitment
by direct action on precursor cells
BMP ----osteoinductive proteins of bone
Hydroxyappatite & titanium may be suitable
carriers for BMP
Induce local bone formation around
implants

Osteoblast
Attachment
Osteoblast exist within / adherent to defined
Protein rich matrix.
Many of the proteins are adhesive extra cellular
Matrix proteins ---posses specific cell attachment
sites
Essential aspect of osteoblast growth &
differentiation
In the context of osseointegration some of the bone
Specific matrix proteins may be components of the
interface

The attachment of cells at implant substrate
Mediated by
Extra cellular matrix proteins
From
Serum &
bone
Control of formation & lifelong remodeling of bone
At the implant interface

Osteoblast proliferation & differentiation
Precursor
Osteoblast
GF,ECM,
Cytokines
Physical strain
Secretory
Osteoblast
osteocyte
Maintaining bone implant interface
Differentiation
Essential for

Molecular & cellular strategies toMolecular & cellular strategies to
improve bone formation at implantsimprove bone formation at implants
Molecular strategies
target
Both cellular proliferation & differentiation
PDGF +IGF-1
TGF beta-1
BMP
TO IMPROVE BONE FORMATION
AROUND IMPLANT
OSTEOPONTIN MAY CONTRIBUTE TO IMP SIGNALS
TO CELLS INVOLVED IN BONE FORMATIONwww.indiandentalacademy.comwww.indiandentalacademy.com

BIO MECHANICAL CONSIDERATIONS
IN OSSEO INTEGRATED PROSTHESES
STRESS TRANSFER FROM IMPLANTS TO BONE
MECHANICAL STRESS --- TRANSFERRED FROM IMPLANT
BONE
FATIQUE CAPACITY
TO AVOID RELATIVE MOTION
ALL THESE REQUIREMENTS ACHIEVED BY
VIRTUE OF THE CLOSE APPOSITION OF THE BONE TO
IMPLANT AT ANGSTROM LEVEL

PROPERTIES OF TITANIUM & BONE
MODULUS OF ELASTICITY YIELD STRENTH
TITANIUM
CANCELLOUS
BONE
1.1×1010
N / M
CORTICAL BONE HAS LOWER M.O.E & STRENTH THAN
CANCELLOUS BONE .
BOND OF THE BONE TO TITANIUM WILL FAIL FIRST
RATHER THAN TI
STRESS ABOVE THE LEVEL OF BONE
LEADS TO
TITANIUM FAILURE
10×1010
N / M
3×1010
N / M
5×1010
N / M

Bone loading
Bone cells are sensitive to strain along functionally
loaded bone loaded bone surfaces
Biomechanical control
of osseous adaptation
Related to
Magnitude & frequency of
Dynamic loading
(intermittent loading)
Bone is a composite biomaterial that structurally adapts to its
mechanical environment

The upper limit of the physiological loading range for
Steady state maintenance of bone
10 %of its ultimate strength (2500 /25000 micro strain
Moderated over loading
10-15 % U.S
Induces hyper tropic response
&optimize structural orientation
Pathological over loading
( >16% U.S
Accumulation of fatigue damage
Localized loss osseous support /
Spontaneous stress fracture

Alveolar bone requires a higher strain to avoid atrophy than does
basilar bone
When teeth are lost , alveolar process often resorbs until basilar
Mandible & maxilla remain
Rigid bone implant restore atrophic bone to masticatory function
Prostheses supported by Osseo integrated implants present unique
Biochemical challenges
Because of
Extended crown
root ratio of supra
structure
Lack of cushioning
periodontal ligament
Compromised
neurological
feed back
mechanism
Control of
Occlusal force

Clinicians must be particularly vigilant in avoiding mechanical
over loading during 1st
year of function
The osseous support is fragile because of
High rate of turn over & lack of mineral maturation

Dynamic loading
Magnitude
Frequency
Peak strain history ( micro strain )
<200
200-
2500
2500-
4000
>4000
Fatigue
failure
Pathological
Over load
Hyper trophyBalanced
Steady
Rate
Atrophy

ClinicalClinical approachesapproaches to describe theto describe the
Osseo integrated interfaceOsseo integrated interface
 Clinical mobility testClinical mobility test
 Radiographs ---radiolucent zones around the implant are aRadiographs ---radiolucent zones around the implant are a
clear indication of its being anchored in fibrous tissueclear indication of its being anchored in fibrous tissue
 (optimal resolution of radiography –0.1 mm)but the size of the(optimal resolution of radiography –0.1 mm)but the size of the
soft tissue range 0.01mmsoft tissue range 0.01mm
Only capable of roughly Indicates
The true tissue response

Histological examination ofHistological examination of
Bone metalBone metal interfaceinterface
 PROPERELY OSSEOINTEGRATED IMPLANT AT THEPROPERELY OSSEOINTEGRATED IMPLANT AT THE
CORTICAL PASSAGECORTICAL PASSAGE
MINIMAL DIRECT CONTACT BONE 0F 90-95% OF THEMINIMAL DIRECT CONTACT BONE 0F 90-95% OF THE
IMPLANT SURFACEIMPLANT SURFACE
OSSEOINTEGRATED IMPLANTS SHOWS HIGH DEGREEOSSEOINTEGRATED IMPLANTS SHOWS HIGH DEGREE
OF BONE CONTACT ALONG SEVERAL THREADS OFOF BONE CONTACT ALONG SEVERAL THREADS OF
SCREW (MICRO IRREGULARITIESSCREW (MICRO IRREGULARITIES ))

PRESENTLY USED
IMPLANTS
I T I-HOLLOW CYLINDER
Tubingen aluminum
device
Brane mark screw
Ex of
Osseo integrated
Core vent
Implant
Sub periosteal
Implant
Lack of bone integration

implantBone
C
O
L
L
A
G
E
N
F
I
L
A
M
E
N
T
S
200 ANGSTROMS
CACIFIED
GROUND
SUBSTANCE
200-300 A*
PROTEO
GLYCANS &
GLUCOSEAMINO
GLYCANS

TISSUE REACTIONS TO CP TITANIUMTISSUE REACTIONS TO CP TITANIUM
VSVS
TITANIUM 6 AL 4 VTITANIUM 6 AL 4 V

BRANE MARKBRANE MARK CPTICPTI CONTAIN 99.75% TI (Fe 0.05% )CONTAIN 99.75% TI (Fe 0.05% )
 Fe content 0.005% strength would be lessFe content 0.005% strength would be less
compared to 0.5%compared to 0.5%
Tissue corrosion
Proteoglycan coats
With out collagen filament
TI 6AL 4V
Collagen free proteo
Glycans
200-400 ANGSTROM
CPwww.indiandentalacademy.comwww.indiandentalacademy.com

METAL ION RELEASE FROM CP TI &METAL ION RELEASE FROM CP TI &
TI6AL 4VTI6AL 4V
 NO ADVERSE TISSUE EFFECTSNO ADVERSE TISSUE EFFECTS
 INDEED PROPER ULTRASONIC CLEANINGINDEED PROPER ULTRASONIC CLEANING
REDUCE Ti LEAKAGE
&
BLACKENING REACTION
BUT IN TI 6AL 4V --V CONTENT INCREASE IN LUNG &
AL CONTENT IN NEURAL TISSUE

IMPORTANCE OF CONTROLLEDIMPORTANCE OF CONTROLLED
SURFACE PROPERTIES FORSURFACE PROPERTIES FOR
OSSEO INTEGRATIONOSSEO INTEGRATION
 ACCORDING TO BAIER ET ALACCORDING TO BAIER ET AL
 TRULY TISSUE INTEGRATED INTERFACE CANTRULY TISSUE INTEGRATED INTERFACE CAN
CARRY MORE LOAD THAN ADJACENT TISSUECARRY MORE LOAD THAN ADJACENT TISSUE
 THE IMPLANTS OF LOW SURFACE ENERGY AT THETHE IMPLANTS OF LOW SURFACE ENERGY AT THE
OF TIME OF INSERTIONOF TIME OF INSERTION
RETAINED BY
POORLY ADHESIVE LAYER FOR A LONG PERIOD OF TIME

Brane Mark Osseo Integrated Implants Characterized By A
High Surface Energy Capable of true tissue integration .
However ,any implant , improper cleaning & handling of
Material
Surface contamination
Poor tissue integration

Any implant material inserted in the body
Rapidly covered by
Protein dominated filmwill
Build to sufficient thickness
Before successful colonization
By adjacent living cell
Albrektson et al demonstrated
Disturbing protein adhesion by treating Ti bone implant with a
glyco protein
Resulting in
Impaired removal force for those implantswww.indiandentalacademy.comwww.indiandentalacademy.com

The importance of controlled surface structure forThe importance of controlled surface structure for
Osseo integrationOsseo integration

Steinemann et alSteinemann et al measured adhesion forces of integrated Timeasured adhesion forces of integrated Ti
implants with a rough surfaceimplants with a rough surface
2 types of stresses
Shear forces
Tensile forces
Steinemann stated that no transmission of forces is possible
During approximately the 1st
20 days after implantation

Later a stage of partial integration occurs , bone in growth in the
rough surface allows shear forces to be carried over the interface but
Any tensile forces will lead to separation
After 90 days
A complete Osseo integration develops
A Tear off strength of sand blasted surfaces increases
(range of 3.5 N /mm)
After 210 days
A plasma coated surface withstands less tensile forces
than a sand blasted surface

Bonding mechanism over theBonding mechanism over the
Osseo integrated interfaceOsseo integrated interface
Van der wall
Interaction
( physical force)
Chemical
forces
Controversies regarding bonding
McQueen et al stated that
Oxide layer of Ti implants was found to be self passivating
Oxide layer increased in thickness with longer durations of
implantation
The Osseo integrated implants may not be quite static ,
But instead the tissue interacting oxides grow over
Periods of 6 to 7 yearswww.indiandentalacademy.comwww.indiandentalacademy.com

Implant screwImplant screw
 Research on implant screw has involved primarily 2 areasResearch on implant screw has involved primarily 2 areas
Ultimate strength Pre load torque
Recommendation of a 10 N cm preload unite a prostheses frame work
/ single crowns component to the abutment using the appropriate
screw is based on the theory that this 10 N mm preload just below the
Yield strength of the retaining screw
Will not cause it to breakwww.indiandentalacademy.comwww.indiandentalacademy.com

Optimum preload for a given type of screw should
be correlated
With correlated with the mechanical properties of
the specific screw

Implant prosthesis and forces
Importance of positioning of implants
Curved arrangement around the arch instead of in a flattened
configuration
Distributing more efficiently the functional forces transmitted
by the prosthetic frame work designs to the implants & bone

Occlusal loading of the implants
If the loading directly over the implant it is a compression force,
While loads in all other force applications are
Bending moments of forces
In those force applications where bending moments occurs ,
Implant nearest the applied load
Compressive force
Experience
Most distant implants
& related components
Tensile forcewww.indiandentalacademy.comwww.indiandentalacademy.com

Healing responses
Since the healing response of bone creates the formation of a complex
Mineralizing matrix ,
The healing response of the biological tissues & the oxide surface
Two phase ceramic interaction
Bet
Hydroxy apatite
Bone matrix
Surface ceramic
oxide

Thickness , composition , reactive nature of the ceramic oxide
Is sensitive to the way in which the surface of the implant is
Cleaned & sterilized by manufacturer
Proper surgical handling of the tissues with minimal generation
Of heat (<47 degree c for 1 min)
Most predictable healing response

SUGICAL STAGES OF OSSEOINTEGRATION
Stage 1 surgery –placement of implant
Stage 11 surgery—abutment connection

Keys to implant surgery success
Minimize the risk of
infection
Minimize tissue injury
Avoid contamination of
Implant surfaces

Initial clot formation
Minor inflammatory response
Proliferation & differentiation
The ability of the tissue to differentiate will depends of
An intact vascular bed
Provides adequate oxygen supply for
Differentiation

Compromised blood supply
Oxygen poor environment
Proliferation of fibrous tissue &
Cartilaginous tissue
Instead of
Mineralized
Bone matrix

Following Initial Placement Of Implant
Thin layer of bone will become
Necrotic in the prepared site
Replaced by
Integration
processInitially in growth of vascular loops
At the rate of 0.5 mm/ day
Initial woven bone formation 1st
2 weeks
Inert nature of oxide surface ,newly differentiating
Osteoblastic cells
stimulates

Woven bone matrix
Initial bone contact with oxide surface
Remodeling process
(removal of woven bone matrix by cutting cones)
Lamellar bone differentiation
( where newly differentiated osteoblast lay down a mature
haversian system)

In time the space bet implant & bone will heal with new
Bone by a reparative osteogenesis
Creeping substitution
Clinical fixation of implant
Results in

Dynamic oxide interface
When Ti & Tialloys exposed to physiological blood
Complex titanium phosphate &ca containing
Hydroxyl groups
Form on the oxide surface
LOW PH (5.2) in the implant bed to accelerate the
Formation of ca phosphate on the pure Ti Surface

The oxide surface plays a role along with bone remodeling
In creating an adaptive interfacial region bet the implant &
body
Thus , the reactive nature of this oxide surface
+
Spontaneous formation of ca phosphate apatite
Ti appear to be biocompatible

Progressive Osseo integrationProgressive Osseo integration
The amount of bone contact vary significantly , depending on
Where the measurement is made any one implant ,& degree
bone contact with progressive remodeling
(degree of bone contact for trabecular bone 30 % & 70%)

Surface preparationSurface preparation
 InvolvesInvolves
material used in fabricationmaterial used in fabrication
surface composition of bulk materialsurface composition of bulk material
ceramic coatingsceramic coatings
(Bio active coating +formation of titanium oxides )
Significant factor in Osseo integration

materials
Commercially Pure Ti
TI 6AL 4 V
Ceramic hydroxy apatite
Surface modifications by plasma sprayed
coatings ,porous surface

Surface composition
The oxide layer is considered integral
part of the implant , depth &
composition of the layer may have a
profound effect on Osseo integration
Most common oxide layer
Titanium oxide (Tio2), Other oxide like
(Tio & Ti2 03)
The oxide layer may have a controlled influence over the
Thickness of collagen free proteinaceous film bet implant & bone
Cp proteinaceous film --- 20 nm
TI 6 AL 4 V proteinaceous film ----500nm

Basic guide to Osseo integrationBasic guide to Osseo integration
Bio compatibility of the implant materials
As proteoglycan layer of 100 A* TO 200A*thickness
Are seen in the normal tissue where no implant has been inserted,
This point suggested CPTI more natural than zirconium
CpTI -----high degree of tissue compatibility &
corrosion resistance
But in stainless steel surrounded by cellular coats &
Wide collagen free proteoglycans
Corrosive in the body

NIOBIUM ARE ABLE TO PRODUCE HIGH DEGREE
OF OSSEO INTEGRATION
IMPLANT DESIGN
HAS A GREAT INFLUENCE ON INITIAL STABILITY &
SUBSEQUENT FUNCTION .
Hydroxy apatite type of calcium ceramic phosphate material
CPTI Implants had 50-75% more interfacial bone than the
hydroxy Coated implants

DESIGN PARAMETERS
Implant length
MOST COMMON LENGTH BET
8 &15mm
Implant diameter At least 3.25 mm required to ensure
Adequate implant strength .
(up to 6.5mm width is available)
Implant shape Hollow-cylinders , Hollow screw ,
solid cylinders
Provides maximize the potential area
To Osseo integration &initial stability
enhance
Minor alteration in
Size & pitch of the threadswww.indiandentalacademy.comwww.indiandentalacademy.com

Surgical techniqueSurgical technique
 Importance of tissue heat controlImportance of tissue heat control
critical temperature of bone has revealed that 47*Ccritical temperature of bone has revealed that 47*C
exposure for 1 min to bone necrosisexposure for 1 min to bone necrosis
Minimal tissue violenceMinimal tissue violence
Continuous careful cooling while surgical drilling performedContinuous careful cooling while surgical drilling performed
At lower rotatory ratesAt lower rotatory rates
Proper drill geometry is importantProper drill geometry is important
Insertion torqueInsertion torque
should be moderate level
Strong torque –results in stress concentrations
Around the threads of screw implant
Bone resorptionwww.indiandentalacademy.comwww.indiandentalacademy.com

Bone factors
Success highly
Dependent upon
Surgical technique
Which avoids
Over heating
Most favorable quality of jaw bone for
Implant
Well formed cortex & densely trabeculated
medullary spaces with good blood supply
Bone which is predominantly cortical bone
Good initial stability
Easily damaged by
Over heating >10mm
In depth

Surface characteristicsSurface characteristics
Smooth implant surface does not become Osseo integration
Implant needs some irregularities for a proper bone response
,but further increasing the surface roughness
Leads to
Ionic leakage
One of the surface measures Sa
represent

Smooth surface implant Sa value 0.1
Poor Osseo integration
Sa value 0.4
( machined surface characteristic)
Roughness value
(1-1.5 )
>2
(plasma sprayed oral implants )
Stronger bone response
Weaker bone response

Implant bed
Healthy implant host site is required
Pt characteristics (Age ,&H/O of proposed host site
smoking
Affect the healing response in Osseo integration
Previous irradiation relative contraindication
Hyperbaric oxygen therapy

Loading conditionLoading condition
 Movement of implant during initial period results in fibrousMovement of implant during initial period results in fibrous
tissue encapsulationtissue encapsulation
 In partial dentate individual it is desirable to provideIn partial dentate individual it is desirable to provide
provisional prostheses (in case of tooth supported)provisional prostheses (in case of tooth supported)
To avoid early implant loading
Mucosal supported denture it is generally recommended
That they should not worn over the implant area for 1 -2 weeks
To prevent the breakdown of soft tissue wound

Systems such as branemark have advised leaving implants
Unloaded beneath the mucosa for 6 months in maxilla &
3 months in mandible
Bone quality can be assessed by measuring the cutting torque
during Preparation of implant
Stability of an implant & increasing bone to implant contact
Quantified by
Resonance Frequency Analysis
Measures the
Stiffness of the implant at the
Bone interface

In some circumstances ----immediate loading is compatible with
subsequent successful osseointegration ,
Providing the bone quality is good &functional forces can be
Adequately controlled

Prosthetic considerationsProsthetic considerations
Carefully Planned functional occlusal loading
Will result
Maintenance of Osseo integration
&
Increased bone contact
Type of prosthetic reconstruction
Occlusal scheme
The lack of mobility in implant supported prostheses
Require provision of shallow cuspal inclines &
careful distribution of loads in lateral excursionwww.indiandentalacademy.comwww.indiandentalacademy.com

Single tooth implant restoration to develop initial tooth contact
On natural dentition
&
To avoid guidance in lateral excursion
Loading also depend upon the opposing dentition which could
be natural teeth ,another implant supported prostheses
/removable prostheses.
Surprisingly high forces can be generated through Rpd

The number ,distributionThe number ,distribution
,orientation,orientation
&&
design of implantsdesign of implants
Distribution of load to supporting bone
Can be spread by
Increasing the number & dimension
Spacing & 3 dimensional arrangement
Of the individual implant very
important
So called tripod arrangement of three
Implants recommended
High load situations

Design & properties
Of implant connectors
A rigid connector provides good splinting
& distribution of loads bet implants
Connector have passive fit on implant
Abutment so that loads are not set up
within the prosthetic construction

Dimensions & location ofDimensions & location of
cantilever abutmentcantilever abutment
 Cantilever ext have the potential to createCantilever ext have the potential to create
High loads ,particularly on the implant adjacentHigh loads ,particularly on the implant adjacent
to the cantileverto the cantilever
The extent of the leverage of any cantileverThe extent of the leverage of any cantilever
should be considered in relt to A-p distance betshould be considered in relt to A-p distance bet
implants supporting the reconstructionimplants supporting the reconstruction
Cantilever ext should not be exceed this lengthCantilever ext should not be exceed this length
& cross sectional design should be adequate& cross sectional design should be adequate
To Prevent flexingwww.indiandentalacademy.comwww.indiandentalacademy.com

Para functional activities
Great cautions should be exercised
Excessive loads lead to marginal
bone loss &component fracture

Minimal success criteria forMinimal success criteria for
dental implantsdental implants
 An individual ,unattached implant is immobile when testedAn individual ,unattached implant is immobile when tested
clinically.clinically.
 Radiographic examination doesn’t reveal any peri implantRadiographic examination doesn’t reveal any peri implant
radiolucency.radiolucency.
 After 1After 1stst
year radiographic vertical bone loss <0.2 mm /yearyear radiographic vertical bone loss <0.2 mm /year
 The individual implant performance is characterized by anThe individual implant performance is characterized by an
absence of signs & symptomsabsence of signs & symptoms
 As a minimum implant should fulfill above criteria with aAs a minimum implant should fulfill above criteria with a
success rate of 85% at the end of 5 years &80% at the end ofsuccess rate of 85% at the end of 5 years &80% at the end of
10 years10 years

Optimum occlusion forOptimum occlusion for
Osseo integrated implantsOsseo integrated implants
Balanced occlusion
Lateral loads can affect the rigid
components of the implant
system (fixture- bone interface)
Fully anchored prostheses
SHORT SPAN
FPD&
Single tooth
replacement
Occlusion should be distributed
in maximum intercuspation &
all cusp interference eliminated
in eccentric positions

Edentulous
Classification
Type of prostheses Optimal occlusal
scheme
Edentulous
Edentulous
Class3/class4
Partially edentulous
Class1 /2
Partially edentulous
Fully bone anchored
FPD
Over denture
Free standing FPD
Free standing FPD
Mutually protected
occlusion
Balanced occlusion
Group function occlusion
Mutually protected
occlusion

Clinical complications of Osseo integrated
implants
Clinical complication
Implant loss as related
To
Type of prostheses &
arch
More implant were lost
- over denture
- maxilla
(fixed complete dentures &
over dentures)
Highest loss ----maxillary over
denture

Implant loss related to
type of prostheses ,
Time after placement ,
implant length , bone
quality.
Most failure occurred with pre
Prosthetically with over denture,
FPD
Post prosthetic failure –single crown
Regarding time –
( post prosthetic )
Implant loss in the 3rd
year was
Significantly lower than the 1st
& 2nd
year
Implant length –
highest failure rate –shorter implan
( 7mm & 10mm)

SURGICAL COMPLICATIONS
NEURO SENSORY DISTURBANCES
HEMATOMAS
COMMON
COMPLICATIONS
AFTER STAGE 1
SURGERY.
MANDIBULAR FRACTURE
LIFE THREATENING HEMORRAGE
DEVITALIZATION OF ADJACENT
TEETH
LESS COMMON

MARGINAL BONE
LOSS
Mean marginal bone loss around
Dental implant in 1st
year
0.4 to 1.6 mm
Subsequent bone loss / year
0 to 0.2 mm
Contributing factor
Remodeling Force tightening of
Implant
Excessive
Amount of
Force

Peri implant soft tissue
Complications
Gingival inflammation /
proliferation
Dehiscence –highly esthetic areas
Soft tissue deficit
Fistulas .
Sub gingival placement of
Implant

MECHANICAL
COMPLICATION
Abutment screw loosening
-single crowns .
-pre molar & molar .
causes
Poorly fitting frame works
Bone remodeling
Release of pre tension in the screw joint
Screw joint movement
Heavy occlusal force

Phonetic & esthetic
complications
Problems mostly in maxilla
Fixed implant supported prostheses
- resorbed anterior maxilla
Often allow air way escape passage
Improper restoration contour
Poor color (shade )
Exposure implant component

conclusionconclusion
Successful osseointegration can only be accomplished in a
Predictable manner by a combination of delicate tissue handling ,
Precise surface science , progressive loading , & a scientific
knowledge of the underpinnings which support this tremendous
Treatment modality

Thank you
For more details please visit
www.indiandentalacademy.com

Osseo integration/ orthodontic continuing education

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